A faculty development program to train tutors to be discussion leaders rather than facilitators.

PURPOSE: During 2003, 2004, and 2005, the role of 70 tutors was changed from that of facilitator to discussion leader, in a preclinical PBL learning course, Gastrointestinal Pathophysiology, by use of three key business school teaching strategies: questions, summaries, and schematics. The purpose of this study was to learn what difference this new approach made. METHOD: During each of the three study years, 171 (2003), 167 (2004), and 170 (2005) students were given Likert-scale attitudinal questionnaires to rate whether their tutors encouraged student direction of the tutorials and whether the summaries and closure schematics benefited their learning. Students' overall course evaluations and mean USMLE scores were quantitatively analyzed, pre- and postintervention. A variety of statistical tests were used to assess the statistical significance of means at the confidence level of .05. RESULTS: In the third year of the program, student ratings indicated that their tutors were significantly better at encouraging student direction of the tutorials than in the first year (P < .05). The students reported that the tutorial made a more important contribution to their learning (P < .05), and the course objectives were better stated (P = .038) and better met (P = .007). Overall satisfaction with the course also improved significantly (P = .006). Part I gastrointestinal system mean scores of the USMLE showed a statistically significant increase in 2005 compared with 2001 or 2002. CONCLUSIONS: The tutor as a discussion leader who questions, summarizes, and uses schematics to illustrate concepts had a significant and positive impact on learning in tutorials, achieving course objectives, improving overall course satisfaction, and increasing a standardized national exam's mean score.

Infliximab: Use in Inflammatory Bowel Disease.

Crohn's disease (CD) and ulcerative colitis (UC) are chronic and often debilitating inflammatory bowel diseases (IBD) without medical cures. Despite the existence of multiple therapies, the medical treatment of these diseases often has proven insufficient and surgery is frequently required. However, as our understanding of the pathogenesis of these disorders and other immune-mediated inflammatory diseases (eg, rheumatoid arthritis and psoriasis) has grown, new and more specific biologic therapies have been developed that are proving more effective than traditional agents. Infliximab is a genetically engineered monoclonal antibody that targets the proinflammatory cytokine tumor necrosis factor-alpha (TNF-alpha) and represents the first effective biologic therapy for IBD and has largely revolutionized treatment. Infliximab initially was developed to be used in patients with moderate to severe luminal or fistulizing CD who are refractory to standard medical therapy. More and more practitioners now are using infliximab as first-line therapy because of its superior efficacy. Infliximab rapidly induces remission in CD, but when given chronically, it can provide long-term maintenance of remission. In addition, there are some data to support its use as a steroid-sparing agent and treatment for various extraintestinal manifestations of IBD and, although used predominantly to treat CD, recent data suggest that infliximab also may have a role in the management of UC. Overall, infliximab represents a clinically useful, cost-effective therapy that works well, even though careful patient monitoring is required to avoid rare but significant toxicities. The hope is that infliximab, together with other biologic agents that currently are in development, will allow us to modify the course of IBD, avoid complications such as strictures and abscesses, and reduce the need for surgery.

The Role of Antibiotics in Inflammatory Bowel Disease.

Broad-spectrum antibiotics are the mainstay of therapy for patients with Crohn's disease (CD) who present with localized peritonitis due to a microperforation bacterial overgrowth secondary to chronic strictures. They are essential adjuncts to drainage therapy for CD-associated abscesses and for complicated perineal disease. The lack of well-designed, placebo-controlled trials has led to much skepticism about the efficacy of antibiotics as primary therapy for CD. However, a careful review of the experience with antibiotics, including clinical observations and controlled trials, leads to the conclusion that antibiotics have a role as primary therapy in active uncomplicated CD. The efficacy of their response must be considered in well-defined subsets of patients. Ciprofloxacin and metronidazole, the two most widely studied antibiotics, are effective therapy for patients with active ileocolonic and colonic disease and have been shown to reduce recurrence rates after ileocolonic resection. The benefits of these drugs are less clear for patients with uncomplicated ileal disease. Additionally, ciprofloxacin and metronidazole may also serve as an adjunct to immunomodulator therapy. The role of antimycobacterial therapy in treatment of CD is an attractive alternative, and hopefully this therapy will be further clarified when results of ongoing trials become available. In toxic patients with fulminant ulcerative colitis (UC), with or without megacolon, broad-spectrum antibiotics should be a part of the treatment program. In less severely ill patients requiring hospitalization, antibiotics may be given to cover for the potential of a superimposed infection until the workup for infection, including Clostridium difficile is completed. There may be a subset of patients with severe nontoxic colitis with persistent fever and bandemia after steroid therapy who respond to antibiotics, but to date controlled trials have not shown efficacy in this group. Antibiotics should not be routinely used for mild to moderately ill patients with UC, although a trial of ciprofloxacin is not unreasonable prior to colectomy for otherwise refractory patients. The use of rifaximin in UC requires further evaluation in larger studies.